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gning this Tax Return and Electronic Funds Withdrawal Consent, it applicable, by entering my Self-Select PIN below. Taxpayer's PIN: Date 09122018 Spouse's PIN: 719986 044)I.17 EFTA00792091 Form 114a Department of the Treasury Financial Crimes Enforcement Network (FinCEN) May 2015 Record of Au
le. if not reporting a personal account 46 Dattlate wlepa Mn the HMO le aottonelIteignel Third Party Preparer Use Only 47 Preparer's last name WEISS 48 First name DAVID 49 MI 50 Check LJ if selfomployedp0096 51 TIN 2062 51a TIN type I XI PTIN 0 SSNATIN Foreign 52 Contact phone no. 212-
Information. 2017 Submission Identification Number (SID) Taxpayer's name ANASTASIYA SIROOCHENKO Social security number ***4**4. Spouses name Spouse's social secure num er . . liPart rl Tax Return Information - Tax Year Ending December 31, 2017 (Whole dollars only) 1 Adjusted gross income (F
sonal account 146 Date (MWDD Ma date will auto.I N Men the FBAR is ay.t.tionaiit ore, Third Party Preparer Use Only 47 Preparer's last name WEISS 48 First name DAVID 49 M 50 Check if self -employed x 51a TIN type I I PTIN SSNATIN Foreign 52 Contact phone no. sza Ext. 53 Firm's name
ormation. 2017 Submission Identification Number (SID) Taxpayer's name ANASTASIYA SIROOCHENKO Spouses name Social security number ***4 "4-9816 Spouse's social security number IPartI Tax Return Information - Tax Year Ending December 31,2017 (whole dollars only) 1 Adjusted gross income (Form 1040,
ing a personal account 146 Date (MM/DD Ma date will auloitnneMn the nswisaanuol el gnea Third Party Preparer Use Only 47 Preparer's last name WEISS 48 First name DAVID 49 MI 50 Checks I if so-mow/3O)00962062 51 TIN 51a TIN type I XI PTIN SSNATIN Foreign 52 Contact phone no. 212-695-577
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